The consumer problems in this category incorporate a wide range of provider access issues. They include general complaints and lack of understanding about the limits on provider access imposed by network-based plans, as well as specific concerns, such as the potential interruption of a valued relationship with a doctor who is being dropped from the plan’s network. Provider access problems are often prompted by an acute episode of illness or diagnosis; consumers seek to disenroll when their current plan will not cover care from a home health agency, skilled nursing or other rehabilitation facility, or from a particular specialist, such as a facility or doctor specializing in cancer treatment. This category also includes cases where consumers were misinformed about the limits on provider access before joining.

Disenrollment Due to Cancer

Cancer diagnoses are implicated in a relatively small percentage — less than 5 percent — of the disenrollments, but these cases are some of the most heart-wrenching and most difficult to resolve for Medicare Rights Center caseworkers.

The majority of cancer disenrollment cases — 63.6 percent — however, involve provider access. The limitations of the private plan networks become apparent after the consumer is referred to a hospital or cancer specialist that is out of network. Treatment of rare or advanced cancers in particular triggers referrals to specialty facilities, such as M. D. Anderson in Houston or Memorial Sloan-Kettering in New York City. During the open enrollment periods, the disenrollments are generally effective the following month. When a person is diagnosed with cancer outside of the open enrollment periods, however, rules that lock consumers into their Medicare Advantage plans for the year generally prevent disenrollment (unless the case also concerns misrepresentation or marketing fraud, as is sometimes the case), and therefore may impede access to the most appropriate cancer treatment facility.

Comment:

By Don McCanne, MD

This survey does not quantify the extent of patient dissatisfaction with Medicare Advantage plans since it was limited to individuals calling the Medicare Rights Center to find out about disenrolling from the private Medicare Advantage plans. But it does provide us with an understanding of why patients want out of their plans. First and foremost patients complain of a “lack of understanding about the limits on provider access imposed by network-based plans.”

The second most common complaint was about misinformation and marketing abuse. This was the primary reason for provider access complaints – the Medicare beneficiaries did not understand that their access would be limited to physicians in plan networks.

This has certainly been infuriating for those who have lost their choice of physicians by enrolling in the Medicare Advantage plans, but it has much greater implications under the Patient Protection and Affordable Care Act. Virtually all plans will have network-based restrictions.

President Obama promised us choice of health plans, but the marketing of his proposal was silent on the fact that virtually all of the plans would have limited access – limited choice of physicians and hospitals – because of provider network restrictions.

With the traditional Medicare program, everyone has free choice of their health care professionals and institutions. That should have been a prime goal of health care reform. It still can be should we decide to enact a single payer national health program – an improved Medicare for everyone.